Amanda Kumar

Occupational Radiation Exposure of Anesthesia Providers: A Summary of Key Learning Points and Resident-Led Radiation Safety Projects:

Anesthesia providers are frequently exposed to radiation during routine patient care in the operating room and remote anesthetizing locations. Eighty-two percent of anesthesiology residents (n = 57 responders) at our institution had a “high” or “very high” concern about the level of ionizing radiation exposure, and 94% indicated interest in educational materials about radiation safety. This article highlights key learning points related to basic physical principles, effects of ionizing radiation, radiation exposure measurement, occupational dose limits, considerations during pregnancy, sources of exposure, factors affecting occupational exposure such as positioning and shielding, and monitoring. The principle source of exposure is through scattered radiation as opposed to direct exposure from the X-ray beam, with the patient serving as the primary source of scatter. As a result, maximizing the distance between the provider and the patient is of great importance to minimize occupational exposure. Our dosimeter monitoring project found that anesthesiology residents (n = 41) had low overall mean measured occupational radiation exposure. The highest deep dose equivalent value for a resident was 0.50 mSv over a 3-month period, less than 10% of the International Commission on Radiological Protection occupational limit, with the eye dose equivalent being 0.52 mSv, approximately 4% of the International Commission on Radiological Protection recommended limit. Continued education and awareness of the risks of ionizing radiation and protective strategies will reduce exposure and potential for associated sequelae.

Future Trends in Regional Anesthesia Techniques

Regional anesthesia is a rapidly expanding field within the practice of anesthesiology. The use of peripheral nerve blocks in routine anesthesia care has increased as evidence for better analgesia, and decreased opioid consumption has supported this practice. This chapter highlights several cutting-edge trends within the arena of regional anesthesia. Fascial plane blocks involve the deposition of local anesthetic between fascial planes without targeting a specific nerve; this chapter discusses several new plane blocks, including quadratus lumborum, pectoral, serratus, and erector spinae plane blocks. Furthermore, the advent of ultrasound has allowed visualization of nearby structures and performance of blocks that otherwise may have too low of a safety margin without visualization. This chapter will discuss some of these blocks, such as parasternal and IPACK (interspace between the popliteal artery and capsule of the posterior knee) blocks. Finally, the chapter will summarize evidence behind the use of long-acting local anesthetic drugs as well as innovative ergonomics as a means to improve our work processes.

Advances in regional anaesthesia: A review of current practice, newer techniques and outcomes

Advances in ultrasound guided regional anaesthesia and introduction of newer long acting local anaesthetics have given clinicians an opportunity to apply novel approaches to block peripheral nerves with ease. Consequently, improvements in outcomes such as quality of analgesia, early rehabilitation and patient satisfaction have been observed. In this article we will review some of the newer regional anaesthetic techniques, long acting local anaesthetics and adjuvants, and discuss evidence for key outcomes such as cancer recurrence and safety with ultrasound guidance.

The use of ultrasound imaging for brachial plexus injury assessment following operative clavicle repair

To the Editor, Clavicle fractures and their treatment can be associated with neurovascular complications; the incidence of brachial plexus injury is 0-1.5%. Brachial plexopathy may be a result of direct or indirect injury such as traction, compression, or entrapment, given the proximity of the brachial plexus within 12 mm of the clavicle. We describe a patient with brachial plexopathy after surgical repair of a clavicular fracture whose diagnosis was confirmed through bedside ultrasonography. This otherwise healthy male presented after a fall with a mid-clavicle fracture. Fifteen days after injury, he underwent open reduction and internal fixation with a Rockwood clavicle pin under general anesthesia. In the postanesthesia care unit, the patient complained of new shooting pain in his arm, numbness of his hand and fingers, and diffuse motor palsy. Discussion with the surgical team revealed a difficult reduction intraoperatively that may have caused a traction injury. One month postoperatively, he continued to have weakness and substantial muscle atrophy. The regional anesthesia division performed an ultrasonographic examination of the brachial plexus, which showed edema of the C5 and C6 nerves as they formed the upper trunk above the clavicle (Figure A). There was minimal edema of the middle and lower trunks. Evaluation confirmed continuity of the plexus without evidence of nerve rupture. At three months postoperatively, the patient noted improvement in pain and motor function. Nerve conduction studies were consistent with a brachial panplexopathy with severe focused involvement of the upper and middle trunks. Repeat examination showed edema of the upper trunk above the clavicle that appeared improved compared to prior evaluation (Figure B). At 12 months postoperatively, he had substantial recovery. Ultrasonography revealed continued improvement in edema of the upper trunk, mirroring the patient’s clinical course (Figure C). Acute iatrogenic nerve injury after clavicular fracture repair predominantly involves the C5 and C6 nerves, upper trunk and lateral cord of the brachial plexus, and suprascapular nerve. While electro-diagnostic tests have been considered the gold standard in nerve injury assessment, they may not provide sufficient information until several weeks after the initial insult leading to delayed diagnosis. Ultrasound can provide reliable information, including dynamic determination of nerve continuity and presence of hematoma, foreign body, scar tissue, and neuromas. Furthermore, ultrasound can serve as a low-cost, quickly accessible adjunct to other diagnostic modalities. Bedside ultrasonography has been used to diagnose complications of clavicular fracture, including subclavian artery pseudoaneurysm associated with brachial plexopathy. High-resolution ultrasound has been used to evaluate traumatic brachial plexus lesions and may be an additional tool in triaging patients as surgical or A. H. Kumar, MD (&) S. A. Grant, MBChB Department of Anesthesiology, Duke University School of Medicine, Durham, NC, USA e-mail: amanda.kumar@duke.edu

Updates in Enhanced Recovery Pathways for Total Knee Arthroplasty

Enhanced recovery after surgery (ERAS) programs for orthopedics involve a multidisciplinary approach to accelerating return to function, reducing pain, improving patient comfort and satisfaction, reducing complications from the surgical procedure, reducing hospital length of stay, and reducing costs. ERAS pathways for patients receiving total knee arthroplasty are different from those having intracavitary surgery; they are less focused on fluid homeostasis and gut motility than they are with optimizing systemic and local analgesics and providing a balance between the highest quality pain control and accelerated return to ambulation.

Decreasing the Incidence of Tuohy-Borst Clamp Connector Disconnections From Perineural Catheters: A Quality Improvement Study

the needle to the subcutaneous or even extracorporeal position. Dr Stimpson and colleagues consider the number of cases with unsuccessful identification of the predefined nerve targets in our article to be “excessive.” In this case, we disagree. In many reports, there is significant variation in the anatomical relationship between the ventral rami (roots) of the lower cervical nerves and the anterior and middle scalene muscles; see, for example, descriptions by Dr Harry and colleagues. To develop a straightforward study protocol, we had to decide on a clear description of the nerve targets. For the interscalene brachial plexus block (ISB), this target was described as the typical formation of the superior trunk just caudal to the transverse process of C6. However, if, for example, the ventral rami of C5 and/ or C6 penetrate the anterior scalene muscles, the common formation of the superior trunk may not be identifiable in the sub-C6 position. Because the commonly described anatomical relationship of the superior trunk lying between the anterior and middle scalene muscles may show variations in up to 40% of patients, we predefined a standardized “plan B.” Allowing for individual (operator or patient) approaches to the nerve (eg, tracing of the nerve roots, several injections) would have introduced significant operator-dependent bias, at least in our opinion. If we understood Dr Stimpson and colleagues correctly, they visualized the suprascapular nerve in the subomohyoid position sonographically in each of more than 100 consecutive patients. Considering the anatomical variation in the number and course of the suprascapular nerve(s), this demonstrates a truly extraordinary degree of expertise. Like Dr Stimpson and colleagues, we too have implemented the subomohyoid suprascapular nerve block in our clinical routine and have conducted this block in more than 400 patients over the last 2 years. Using our approach for identifying the suprascapular nerve, which is conceptually the same as Dr Stimpsons technique, we still observe problems in clearly identifying the nerve in the subomohyoid position in approximately 15% of patients. The volume of local anesthetic injected for ISB or suprascapular nerve block continues to be a matter of dispute among researchers and clinicians. With increasing experience in both techniques, we also reduced the local anesthetic volumes injected. We currently use 10 mL for both techniques (ie, ISB and suprascapular nerve block) and continue to find similar results for numerically rated pain (numeric rating pain scale) and duration of analgesia compared with those presented in Figure